This is an application
forclaims-made
coveragefor the following
professional services performed for others:

tax preparer or enrolled
agent services, including tax advice

bookkeeping services

payroll processing
services

data processing services

notary public services

recommending and installing
hardware and software including training your client in the use of hardware and
software.

Optional coverageis available for services as a financial
planner, registered investment advisor, registered representative and life agent
when services are rendered to implement a written financial plan. Coverage is limited
to the recommendation, sale, and/or management of the following "Financial Products"
and "Insurance Products".

financial instruments
insured by the FDIC;

United States treasury
securities and savings bonds;

bonds issued by
U.S. based entities that have a Moody's Investors Service Financial Strength rating
of Baa or better;

mutual funds registered
with the Securities Exchange Commission;

equities traded
on U.S. or Canadian exchanges issued by an entity able to meet the minimum capitalization
and other requirements to maintain listing on the NASDAQ SmallCap Market. This does
not include real estate investment trusts;

variable life products,
variable annuities, fixed annuities, life, health, accident or disability contracts
issued by an insurance company that have an A.M. Best Financial Strength rating
of B or better.

Personal Information

Your Name:

Desired Effective Date:

/

/

Firm Name:

E-mail Address:

Address:

Telephone:

-

-

Address2:

Fax Number:

-

-

City:

State:

Zip:

Check here to receive your quote via fax:

Qualifying Questions

After inquiry of all owners, partners and officers of the firm:

1
.
No firm member or employee is a licensed CPA.

TrueFalse

2
.
No firm member or employee is aware of any act, omission or fee dispute which might be expected to be the basis of a claim or suit against the firm, firm personnel, or the firm's predecessors in business.

TrueFalse

3a
.
Within the past 5 years, no firm member or employee has been the subject of any regulatory investigation or inquiry; suspended from practice; or charged, indicted, plead guilty or convicted of any felony charge.

TrueFalse

3b
.
No firm, its members or employees have had any disclosure events or reportable events on their respective Form U-4, U-5, U-6, or Form ADV or similar document.

TrueFalse

4
.
Within the past 5 years, the firm has not prepared any financial statements that have been used in any securities offerings whether public, private, registered, or unregistered.

TrueFalse

5
.
Within the past 5 years, no firm member or employee has had any professional liability insurance declined, canceled or non-renewed (Not applicable in Missouri).

TrueFalse

6
.
Within the past 5 years, the firm, its predecessors in business, and associated owners and employees have had no more than 2 claims including suits, settlements, arbitrations, and mediations.

TrueFalse

7
.
Within the past 5 years, the total amount paid or reserved on claims, settlements, and/or arbitrations against the firm, its predecessors in business, and associated owners and employees is no more than $10,000.

If you responded 'True' to all statements above,
you qualify for the Plan. Please complete the information requested and return it as soon as possible.
Once your application is received, we'll send you a quotation. If you do not qualify,
you can call Affinity Insurance Services toll-free at 1-866-225-8464 to speak to a representative about coverage options available to you.